The following Statement was made in the House of Commons on Wednesday 8 June.
“With permission, Mr Speaker, I will make a Statement on the independent leadership review of health and social care.
This is an important report that comes at a critical time. This Government are embarking on a huge programme of reform to tackle the Covid backlogs, to improve people’s experience of the NHS and social care, and to place this system on a sustainable footing for the future. But we cannot seize this opportunity and deliver the change that is so urgently needed without the best possible health and care leadership in place, because great leaders create successful teams, and successful teams get better results. So a focus on strong and consistent leadership at all levels, not just on those who have the word ‘leader’ in their job title, will help us in our mission to transform health and care and to level up disparities and patient experiences.
This review, which I have deposited in the Libraries of both Houses, was tasked with proposing how to deliver a radical improvement in health and social care leadership across England. It sets out a once-in-a-generation shake-up of management, leadership and training, as well as how we can make sure that health and care is a welcoming environment for people from all backgrounds, free from bullying, harassment and discrimination.
The review was led by General Sir Gordon Messenger, former Vice-Chief of the Defence Staff, and Dame Linda Pollard, the chair of Leeds Teaching Hospitals NHS Trust. I thank them both for taking on this role and providing their varied experience of leadership, along with everyone in their review team who has contributed to this important review.
Before I turn to the recommendations of the review, I shall update the House on its findings. The review found that, although there are many examples of inspirational leadership within health and social care, from ward to board, these qualities are not universal. The report states that
‘there has developed over time an institutional inadequacy in the way that leadership and management is trained, developed and valued.’
As a result, careers in management are not viewed with the same respect and prestige as clinical careers. The review also found
‘too many reports to ignore’
of poor behaviour, and that the acceptance of bad behaviours such as discrimination, bullying and responsibility avoidance has become ‘almost normalised’ in certain parts of the system.
We must accept only the highest standards in health and care, where failures in culture and leadership can make the difference between life and death. So we must do everything in our power to share and promote brilliant, innovative management and to act firmly where standards fall short. This means culture change from the top of the system to the front line. The review identifies a number of areas where improvement is needed, and it makes seven transformative recommendations. I will quickly update the House on each of them in turn.
First, the review recommends new measures to promote collaborative leadership and to set a unified set of values across health and care. This includes a new national entry-level induction for new joiners to health and care, and a new national mid-career programme for managers.
Secondly, the review recommends that we should agree and set uniform standards for equal opportunities and fairness, with more training to ensure that the very best leadership approaches become ingrained. The Care Quality Commission must support this work by measuring progress through regular assessments. This does not mean more people working in diversity, but fewer. In my view, there are already too many of these roles and, at a time when our constituents are facing real pressures on the cost of living, we must spend every penny with care. Instead of farming out this important work to a specific group of managers, it must be seen as everyone’s responsibility, with everyone being accountable for extending fairness and equal opportunities at work.
Thirdly, the review recommends a single set of unified leadership and management standards for NHS managers. These standards will apply to everyone, including those who work part-time and flexibly, with a curriculum of training and development to help people meet them. This modernisation is well overdue, and completing the training should be a prerequisite for advancing to more senior roles.
Fourthly, the review recommends a more simplified, standardised appraisal system for the NHS, moving away from variation in how performance and career aspirations are managed towards a more consistent system that takes into account how people have behaved, not just what they have achieved.
Fifthly, the review identifies a lack of structure around careers in NHS management. It proposes a new career and talent management function for managers at a regional level, to oversee and support careers in NHS management and to provide clear routes to promotion, along with training and development.
Sixthly, the review recommends that the recruitment and development of non-executive directors needs to be given greater priority due to their vital role in providing scrutiny and assurance. It proposes an expanded specialist appointments team in the NHS, tasked with encouraging a diverse pipeline of talent.
Finally, there is currently little or no incentive for leaders and managers to move into the most challenging roles, as the barriers are often seen as simply too high. I want leaders in the NHS to seek out those roles, not shy away from them. It is essential that we address that and get great leaders into areas that feel left behind. The review proposes an improved offer, with stronger support and incentives to recruit top talent into those positions.
We will be accepting these comprehensive, common-sense recommendations in full. The recommendations have been welcomed by groups representing people who work throughout the NHS, including by the NHS Confederation and NHS Providers. By taking the review forward, we can finally bring how we do health and care leadership into the 21st century, so that we have the kind of leadership that patients and staff deserve, right across the country, and so that we make sure that some of our country’s most cherished institutions can thrive in the years ahead. I commend this Statement to the House.”
My Lords, I thank everyone who works in the NHS for their continued dedication and skill. We owe them our gratitude. I also put on record my thanks to General Sir Gordon Messenger and Dame Linda Pollard for leading this very important review.
We know that we are at the foothills of a huge programme of NHS reform and reorganisation, which your Lordships’ House carefully scrutinised during the passage of the Health and Care Act. It came through loud and clear that the healthcare system requires proper leadership and a workforce that has enough staff to do the job, something that we know is not the case at present nor is suitably in the pipeline.
I confirm that these Benches support the review’s seven recommendations and welcome that the Secretary of State has already agreed to implement them. However, the critical thing will be to see whether, when and how the proposals are implemented and we will keep a close eye on this. Regrettably, we have too often seen the commissioning of a review by Ministers only to see those same Ministers drag their feet on implementing the recommendations or shelve them completely. Will the Minister give us today a firm date for when he intends to publish the plan to implement the seven recommendations?
The social care survey from the Association of Directors of Adult Social Services shows that more than 500,000 people are waiting for a social care assessment in England, and we need swift action to alleviate this. Will the Minister explain why the review has not covered leadership in social care or primary care in sufficient detail? Is not this a missed opportunity?
Of course, this review is just one part of dealing with the crisis that the NHS faces. New staff getting an induction when they first join the NHS is sensible, but that is just a basic requirement of any organisation worth its salt. We all know that there are bigger, real mountains to climb. Waiting lists are at a record high: 6.4 million in the queue for treatment—nearly one in 10 people—patient satisfaction is at its lowest since 1997, and there have been longer waiting times for cancer treatment in every year since 2010. So it goes on.
There are currently 106,000 vacancies in the NHS, and staff are leaving in droves. In many specialities, they are leaving faster than they can be recruited to those vacancies. It remains to be seen how a shake-up for management will help our health outcomes and alleviate pain and suffering when there are not enough front-line staff. This has to be the Government’s focus.
Yesterday, the Secretary of State talked about the 15-year workforce strategy that he has commissioned. When can we expect it? It would be much appreciated if the Minister could put more flesh on the bones of this brief reference yesterday. Who will be leading this and what will be its terms of reference?
It would be negligent not to mention the role that managers played in the North East Ambulance Service cover-up. The Government are still considering whether to launch a review. Will the Minister provide an update? Surely, if management is to be improved, there is a need to learn from the times when it fails. The incidents at the North East Ambulance Service are a clear case in point.
Finally, it is regrettable that NHS senior leadership still does not represent the diversity of the population that it serves. How will the Government drastically improve equality, diversity and inclusion? And how will the best leaders—whether or not they have a so-called good network—be encouraged, prepared and brought into the most challenging roles where we need to see them?
These Benches welcome the review and its recommendations, but there are many outstanding questions while the NHS is in dire need of support and a workforce able to meet the demands and serve the people who need it.
My Lords, from these Benches we also thank all the staff in the NHS and social care sectors, and specific thanks go to General Sir Gordon Messenger and Dame Linda Pollard for this excellent report. We too support the recommendations in the report.
The Liberal Democrats believe our NHS is in desperate need of support. We need to remember that there are well over 100,000 NHS staff vacancies—and an equally worrying number in the social care sector—and we are concerned about the impact of these vacancies on patient safety.
With millions now waiting for treatment and waiting times increasing, it is more important than ever that the Government address the workforce crisis facing health and social care. We have just come this afternoon from debating two key issues in Grand Committee that the NHS faces: managing RSV and other respiratory infections, and managing neurological conditions.
The two sectors have serious staff shortages in clinical health and that is replicated right across the NHS. After a gruelling couple of years, many staff are considering leaving or retiring early. The Government need to get a grip on this workforce crisis and seriously start planning for the long term, giving the crisis the attention it deserves. I too echo the question from the noble Baroness, Lady Merron, about when the workforce planning draft will first be presented to Parliament. It is urgently needed.
This leadership report is blunt. It highlights the current absence of accepted standards and structures for the managerial cohort within the NHS and says that it has
“long been a profession that compares unfavourably to the clinical careers in the way it is trained, structured and perceived”.
And that is not just inside the NHS. Far too many people—even Ministers—slam managers as unseen, expensive bureaucrats. This report calls that out, as well as recognising that consistent standards and improvement are needed. That is welcome.
The recommendation for a new national entry-level induction for all who join health and social care, as well as national career programmes for managers right across the sector, is very welcome, but what plans do the Government have now for the interim? The crisis is with us—we see it every night on the television news—and the benefits of training and culture change will take some time to bear fruit.
The executive summary advocates a step change in the way the principles of equality, diversity and inclusion are embedded as the personal responsibility of every leader and every member of staff. It goes on to say that good practice is by no means rare but it is not consistent throughout the NHS, and it raises particular concerns about the experience of those with disabilities or race-protected characteristics. We agree with the report’s proposals that EDI should become a universal indicator of how the system is working.
The fourth recommendation in the report on the simplified standard appraisal system is also welcomed, alongside consistent management standards and consistent accredited training. The talent management recommendations are also excellent.
We welcome any measures that seek to improve the way the NHS works, such as the Government’s pledge to build more hospitals, but many of our senior NHS managers struggle with failing buildings that, rather like our Parliamentary Estate, need urgent repair or replacement—but until then they have to try to make them safe. My own local hospital, Watford General, is a case in point. With that in mind, will the Minister please tell us how he proposes to unblock the delays to meet his Government’s pledge of 40 new hospitals by 2030?
Yesterday, the Secretary of State likened the NHS to the now-defunct video store Blockbuster, saying that the country has a
“Blockbuster healthcare system in the age of Netflix”
and that things would change by 2030. To date, only six projects that predate the Prime Minister’s premiership have started construction, despite the Government’s 2019 election pledge that 40 would be built by 2030.
A core theme of the report is collaboration. It reports pockets of excellent practice but also pockets of stuck and poor practice. The report is clear that a real culture change is needed now. In some parts of the NHS there is still an “ignore if not invented here” approach that must be challenged and changed.
Leadership is indeed key to a well-functioning health service, but having enough staff to care for patients is critical to reducing waiting times and improving patient outcomes. Ministers seem keen only on tinkering with leadership programmes. They seem to be ignoring the huge number of vacancies in the NHS and recently refused to write workforce planning and projections into law. So what additional steps will they take to increase the number of doctors and GPs working in our health service in the next nine months? Workforce shortages across the health and social care sector are leading to long wait times and poor outcomes.
Our NHS leaders have done a sterling job steering the NHS through the pandemic and now they are trying to tackle record-breaking waiting times. Leadership is pivotal to the success of any organisation, and the example set by the head of the organisation plays a huge part in that success.
It is a shame that the report focuses only on the NHS and not on the department, because it is important that we remember that two areas over which the Secretary of State’s predecessor, Matt Hancock, had power were PPE and test and trace, both of which were extremely badly handled in leadership terms. Does the Minister agree that leadership starts with Ministers? In an exchange between the Secretary of State and General Sir Gordon Messenger published yesterday, the Secretary of State said, “Leadership is critical”.
Finally, the most welcome chapter of the report is the final one, chapter 4, on implementation. The authors set out a clear route map for making this happen through the establishment of the review implementation office. I note that, yesterday, the Secretary of State said that he accepted all the recommendations. From these Benches, we will hold him to account for the resources necessary for the review implementation office to deliver them.
My Lords, I thank the noble Baronesses for their questions and for their general welcome for the tone of the Messenger report. I also pay tribute, as did the noble Baronesses, to Sir Gordon Messenger and Dame Linda Pollard for their combination of leadership skills as well as clinical and medical knowledge. I pay tribute too to the number of people who were consulted across the system who fed into the report.
I shall try to address some of the questions that were asked. The Messenger report looked at both health and social care. It was interesting that reference was made to reports being published but nothing being acted on. I think we can be proud that, for the first time, we are now aiming, as is set in law following the passing of the Health and Care Act, for a properly integrated health and care system. We can now work to that properly across the system.
In December 2021, the Government published their strategy for the adult social care workforce in the People at the Heart of Care: Adult Social Care Reform White Paper. Our strategy aims to create a well-trained and developed workforce, a healthy and supported workforce, and a sustainable and recognised workforce. Work that has already started includes the review of the existing workforce and the voluntary register to look at the workforce landscape and the various qualifications. We also want to look at how we make sure that the workforce is professionalised and that people feel attracted to it as a career. The strategy is backed up by an historic investment of at least £500 million for new measures over three years—noble Lords will be aware of that.
Both noble Baronesses raised workforce planning. During the debates on the Health and Care Bill, I made it quite clear that where we disagreed with some of the amendments was on the frequency of the reports that was called for. Let me be quite clear about what we are doing in terms of workforce. First, we have the Health Education England strategic framework to support long-term planning. The department commissioned HEE to review and renew the long-term strategic framework for the health and regulated social care workforce—the right skills and the right values and behaviours to deliver world-leading services. The work is nearing its final stages and will be published before the Summer Recess.
Building on this, we have also commissioned NHS England and NHS Improvement to develop a long-term plan for the workforce for the next 15 years, including long-term supply projections. We will share the key conclusions of this work as soon as it is ready. Section 41 of the Health and Care Act 2022 gives the Secretary of State a duty to publish a report at a minimum of every five years describing the NHS workforce planning and supply system. The report provided for in that section will increase the transparency and accountability of the workforce planning process. On top of this, rather than everything simply being top down—the person in Whitehall or Westminster telling local services what to do—there is also the bottom-up planning, at trust level and ICS level, looking at the right workforce and skills mixes required on the boards and in the services to deliver the right services to patients.
The noble Baroness referred to the North East Ambulance Service. This highlights why this report was so badly needed. My right honourable friend the Secretary of State for Health and Social Care said yesterday in the other place that he was very concerned by what he has heard about the ambulance service and that he is not satisfied with the review that has already been done. He said that we need a much broader and more powerful review; he will have more to say about this very shortly.
We welcome the report. We have rightly said, as both noble Baronesses have said, that we welcome all the recommendations. To ensure that these are delivered as quickly as possible and with the right impact, an implementation plan co-created across the whole health and social sector is required. This report will therefore be followed by a plan with clear timelines and deadlines for delivery.
I am grateful to both noble Baronesses for raising the issue of discrimination and lack of diversity. It is interesting that our public services post war were rescued by immigrants from Commonwealth countries—from Africa, Asia and the Caribbean—yet, amazingly, we do not see them at the top of these organisations. Why is that? Frankly, we must move away from this position of white people stopping black and Asian people from being promoted and fobbing them off as “diversity officers”. They do not want to be diversity officers. We are good enough to be leaders and we must ensure that this is instilled right through our health and social care system, not just at the bottom level but all the way up. That will be the test of true diversity and true openness to equality.
There has been some positive movement towards tackling discrimination. The NHS people plan established a set of robust and comprehensive initiatives thought to imbed equality, diversity and inclusion. The recruitment and promotion practices have been overhauled and there will be named equality champions, but we must ensure that this is not just fobbing off. We need to see more diversity right at the top of our health and care system.
If I have not answered the noble Baronesses, I will write to them.
It is tragic that so many babies and mothers have died when they should have been safe in hospital. What happened to the standards of care which were required? Fresh young enthusiastic people joining the NHS and those in care should be safe from bullying, harassment and discrimination. If something goes wrong with patients’ treatment and care, should there not be a duty of candour, with openness and honesty? Surely this should be incorporated in leadership education. I hope that it will be.
The noble Baroness is absolutely right that there should be a duty of candour. Noble Lords will remember that during the Health and Care Bill debates there was the debate around the openness of HSIB process. Here we have a difficult balance. On one hand, if someone has acted inappropriately or caused damage, you would want them to be brought to justice but, on the other hand, we know that the NHS has a culture of cover-up when things go wrong. It is great that we praise the NHS when things go well but I have heard too many stories of when things go wrong and clinicians close ranks and cover up.
Sometimes, they gaslight. I was talking about this the other day to a young official in the department and she told me about her friend, a young Afro-Caribbean female, whose baby died during birth. When she complained, the papers suddenly, magically disappeared. How can that happen? We have to make sure that there is real justice, but we have to get the right balance. HSIB makes sure that there is a safe space so people can feel free to come forward, so that we learn from that. Sometimes there may not be justice for the individual, but we can make sure that we avoid a repeat of these incidents. The Ockenden report clearly showed the role that the culture of the organisation played. We must be careful: there should not always be a focus just on numbers; we do not want to train people within the wrong culture and do more damage. We have to tackle all these issues at the same time.
My Lords, I would congratulate the Secretary of State Sajid Javid on presenting this report if it called for fewer full-time equality, diversity and inclusion officers and devoting resources, intention and focus to patients. Sadly, on reading the report, it does not; quite the reverse. It is totally obsessed with EDI. EDI is mentioned three times as frequently as patients. There is no mention of waiting lists, whistleblowers, cover-ups or value for money, and only one reference to efficiency. There is nothing about the lessons of Staffordshire or the failures in the health service—nothing at all. It is about EDI only. Worst of all, it states that demonstrating a commitment to EDI is more important than just technical skills.
It is important that we eliminate discrimination from the health service, but when I am treated, it is the technical skills of the medical staff I am worried about, as it is when those whom I love are being treated. The report sets goals for increasing the representation of underrepresented groups, but no goals for improving outcomes for patients. Worst of all, it proposes using the everyday discrimination scale as an objective tool of management, yet it is entirely subjective and all the academic literature I have found suggests it is completely worthless. Will my noble friend commission another report that will deal with people’s real concerns about the NHS?
I thank my noble friend for the question. It is important that we recognise that not only do we have more doctors and nurses than ever before, but we need staff to be good leaders. That includes understanding diverse workforces and, as I said earlier, making sure that we have good leaders at the top. Why do we have a diverse workforce? In fact, that diversity is not represented right at the top, in the leadership. Sometimes, when you want to change an organisation—I am sorry, but I did an PhD in organisational change—there are a number of aspects and one of them is the culture and the leadership. Sometimes a new leadership comes in that can drive that change in the organisation. It is not just about structures but about making sure that we improve the standard of care we give to people. This issue came up in the report, because we have to have the right leadership and focus on patient care and on making sure that we have a proper integrated health and social care system for patients all the way through their lives.
My Lords, I welcome the report, and particular work needs to be done in the area the Minister has just described. The NHS is very diverse, more than most public sector groupings. Therefore, if there is a problem there, it needs addressing and it should be given high priority.
First, the real issue that worries the public at the moment concerns the little statement sneaked out by the Secretary of State that he has now agreed to a 15-year work strategy being prepared. The public are worried about the great number of unfilled vacancies in the National Health Service. That number continues to rise, and we now have more than 100,000 vacancies. The public expect the Government to move in a number of ways to try to fill those vacancies, rather than simply waiting for a long-term strategy. Will the Minister tell the House what new ideas the Government have to fill the vacancies? I know that is not an easy question to answer.
Secondly, I suggest that the Government have conversations with the agencies, which supply staff to so many different places in the NHS at such high costs, to see whether some accommodation could not be reached with them. Thirdly, I have personally had experience recently of being treated in the private sector. I spent some time talking to the staff, many of whom were ex-NHS and said they would never return to it. I would like to know what work has been done by the Government in exploring the views held by those people who have left NHS service to establish why they have gone, and what they would need to see change in the NHS to encourage them to return to it.
I thank the noble Lord for that question. We should look at the context of the different environment and the challenges that our health service and health and social care system is facing compared to in earlier years. A number of different factors have come together. One is that we have an ageing population and people are living longer but not necessarily living longer well, and therefore, where before the focus was mainly on physical treatments, we are now far more aware of issues like dementia and the challenges presented by ageing populations. On top of that, we are simply aware of more conditions. I have just come out of a debate on neurological conditions, of which I was told that there are probably 600. When I was a child, that probably would have been dismissed—no one would have thought that there were such a number—so there is more awareness of the issues to be treated.
Mental health is now treated more seriously. It was never taken seriously before; it was always about “pull yourself together” or the stiff upper lip, but now we understand that people have mental health conditions. We need to make sure that we have a health and care system, including private and independent, that can meet those needs.
One of the challenges is that we need more doctors and nurses. The funny thing is that we actually have more NHS doctors and nurses than ever before, but we recognise that on top of that we still need more. Investing in the workforce is therefore a key priority.
There is the 15-year plan, as I have said. The NHS also has the people recovery task force to make sure that all NHS staff are not only kept safe but retained. There are a number of initiatives, which I am happy to write to the noble Lord about, about helping staff who feel burned out, as well as retention programmes.
On top of that, we have increased the number of medical school places. We have found that students are sometimes more likely to stay close to areas where they have studied, so new medical schools have opened in some of those places which have found it hard to recruit. We also have more new nurses coming through the system but, despite that, there is still demand for more. We are looking at various ways to improve retention but also attract new staff.
My Lords, I echo the point made by my noble friend Lady Merron about the health service and the people who have done such sterling work within it. After all, they saved my life twice so I certainly recognise that.
However, I have to say that, like the report, the NHS is a bit of a curate’s egg, and we know it; it is good in parts. When it is good, it is very, very good, but when it is bad, it is dreadful—really dreadful. People die unnecessarily, as we saw in the gynaecology scandal at Telford. What worries me about that case is that I still do not see anyone being held to account for those appalling management failures. Even worse than that is the report yesterday from Birmingham of the consultant who was removing non-existent cancers from breasts and went on to practise for years without being uncovered, not only in the NHS but in private practice. We have to ask ourselves how on earth such appalling failures in accountability, management and checking are possible. I would welcome the Minister’s response on that.
I recommend that the Minister look at the Twitter account of a guy called Roy Lilley, because it is worth a look. I will give a flavour of it:
“There’s a problem with bullying and racism in the British Army. A BBC Three documentary shone a light on racism in the Army and there is still the shadow, cast by the events at Deepcut. It’s a hot topic for the Top-Brass. They’ve had reviews and all-sorts to try and stamp it out”—
and they failed. He continues:
“If they can’t fix racism and bullying in a small outfit like the Army, what chance does the NHS have … with around a million and a half people, a budget of about £3bn a week, a million customers a day and if it were a country it would be the thirtieth largest in the world. In the Army, the NHS, sport and wider society we’ll find good people, bad people, energetic, lazy, thieves, thugs, saints, angels, bullies and racists”—
I will, but hardly anyone has contributed to this debate. I have posed one question and I will pose a few more—I do not see why I should not take the opportunity. I would see why if the Chamber were full of people participating, but it is a bit rich that there is hardly anyone—
I have posed one question, and I will pose a couple more. I will move to further questions and my criticism of the report. First, I agree with a lot that the noble Lord, Lord Lilley, said. On diversity, we recently had a situation, on which I would welcome a comment from the Minister, where the NHS could not bring itself to define a woman in gynaecological circumstances—I find that somewhat unbelievable.
What are we doing about fixing the situation in A&Es where paramedics stand by trolleys for hours on end while people are dying of strokes outside? I have raised this question with the noble Lord a number of times. It can be fixed, but you have to be determined. If the noble Lord wants an example of best practice, I recommend that he look at Wolverhampton, where he will find an example. There is no mention of best practice in this report, which I find astonishing. I also note the importance of new technology being adopted in a coherent way. I look forward to the Minister’s answers to those questions.
I thank the noble Lord for his questions. I say up front that I am not a fan of Twitter, even though I am still on it. Frankly, I do not like social media and I try not to look at it too much—but I welcome that the noble Lord shared some of his concerns.
The noble Lord is absolutely right on bullying and harassment; they are not acceptable in any form and should not be tolerated—this is part of the NHS people plan. This goes to the heart of the review: it is about leadership and culture. We have to make sure that there is a culture where bullying and discrimination are not tolerated. Frankly, it is about not diversity officers but greater diversity, which are not always the same. As I said, we have a diverse workforce, but why do we not see more diversity in the upper echelons of our health service? It is important that bullying is tackled and that we have that culture—but this also comes from local leadership.
I am grateful to the noble Lord for the number of times that he has suggested thinking outside the box on A&E. We have looked at various pressures on it; sometimes people go to it because they cannot get a GP—how do we address that? Sometimes, people do not want to go to A&E and try other routes but end up there—so how do we make sure that those other routes are available? We are looking at how to triage better and how people can use 111 instead. There are a number of issues and, as the noble Lord rightly said, technology can play a role.
House adjourned at 5.59 pm.